EPIC: ED Transfer Note

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ED Admit to Inpatient Rm

EPIC: ED: TRANSFER NOTE

ATT: @ATTPROV@
PCP: @PCP@
@NAME@ @AGE@(@BDAY@)
@DEPTNME@
@RRHLOS@
MRN: @MRN@

Current attending in ED: @ATTPHY@

SYNOPSIS

@NAME@ is a @AGE@ @SEX@ ***
@NOTESUMMARIES(1&0&0)@

{SNP Linked Labs:23727}

Admitted for
@PROBLEM@

@PROB@

NURSING HANDOFF

Plan: Pending workup/admit . All questions answered to the patient’s satisfaction. All personal belongings were with the patient including all electronics, clothing, and valuables. Pt sent w/medical paperwork. Charge RN aware.

DISPO: NAD, VSS

BELONGINGS: clothing and cell phone

REPORT GIVEN TO: RN

TRANSPORTATION: gurney via tech

DESTINATION: tbd

ASSESSMENT

NOTES ENDORSED TO RECEIVING NURSE:

NEURO:

  • Aoxo4

RESPIRATORY:

  • No SOB

CARDIAC:

  • NSR

GI:

  • swallows pills ok

{SNP Linked Labs:23727}

@DIETORD@

GU:

  • uses urinal

SKIN:

  • normal

FAMILY:

  • at bedside

VITALS

VITALS
24 Hour Min / Max Current
@FLOWSTAT(6:24::1)@ @FLOW(6:last:1)@
@FLOWSTAT(5:24::1)@ @FLOW(5:last:1)@
@FLOWSTAT(8:24::1)@ @FLOW(8:last:1)@
@FLOWSTAT(9:24::1)@ @FLOW(9:last:1)@
@FLOWSTAT(10:24::1)@ @FLOW(10:last:1)@
Admit: @FLOW(14:first:1)@ @FLOW(14:last:1)@ @BMI@

LAST VS:
@VS@

LABS

@LABBRIEF(NA,CL,BUN,K,CO2,CREATININE,GLUCOSE)@
@LABBRIEF(WBC,HGB,HCT,PLATELETS)@
@LABBRIEF(PT,INR,APTT)@

@LABBRIEF(CA,MG,PHOS)@

@LABBRIEF(ALB,LACTICACID,LACTWBVENPC,TROPONINHS,HGBA1C)@

@LABRCNT24(POCGLUCOSE:*)@

DRIPS

ICU DRIPS & CONTINUOUS IV’s
LINES:

PIVs

IMAGING

@IMAGERESULTS48H@

NURSING PLAN

Maintenance Tasks
-add/maintain PIVs, check need for CVC/Foley
-monitor electrolytes
-strict I/o when ordered
-neuro checks periodically
-monitor HGB; check s/s bleeding
-ensure airway trach patency
-elevate arms, if app
-d/w attending pt status
-turned pt q2h
-fall risk observed
-wound care/prevention as necessary
-skin checks q shift w/RN 4 eyes verification

Report given to oncoming RN, , at transfer, who then assumed all care.

Howie Realubit, BSN, RN, CCRN
Electronic Signature
@TD@ @NOW@

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